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Paramedic assessment of pain in the cognitively impaired adult patient
Bill Lord
BMC Emergency Medicine , 2009, DOI: 10.1186/1471-227x-9-20
Abstract: A systematic search of health databases for evidence relating to the use of pain assessment tools that have been validated for use with cognitively impaired adults was undertaken using specific search criteria. An extended search included position statements and clinical practice guidelines developed by health agencies to identify evidence-based recommendations regarding pain assessment in older adults.Two systematic reviews met study inclusion criteria. Weaknesses in tools evaluated by these studies limited their application in assessing pain in the population of interest. Only one tool was designed to assess pain in acute care settings. No tools were located that are designed for paramedic use.The reviews of pain assessment tools found that the majority were developed to assess chronic pain in aged care, hospital or hospice settings. An analysis of the characteristics of these pain assessment tools identified attributes that may limit their use in paramedic practice. One tool - the Abbey Pain Scale - may have application in paramedic assessment of pain, but clinical evaluation is required to validate this tool in the paramedic practice setting. Further research is recommended to evaluate the Abbey Pain Scale and to evaluate the effectiveness of paramedic pain management practice in older adults to ensure that the care of all patients is unaffected by age or disability.Although pain is a commonly encountered complaint in prehospital and emergency medicine settings, evidence of inadequate analgesia has been widely documented. Poor pain management practice has been described in the emergency department (ED)[1], and variations in pain management practice in this setting have been associated with ethnicity[2], gender[3], and extremes of age[4].Reasons for inadequacies in pain management practice are likely to be multifactorial. Failure to assess for the presence and severity of pain may be one factor, as efforts to make pain measurement mandatory in the ED have been sh
Environmental Factors Preceding A 40 Monomer to Oligomers and the Detection of Oligomers in Alzheimer's Disease Patient Serum  [PDF]
Yoichi Matsunaga,Midori Suenaga
Journal of Amino Acids , 2012, DOI: 10.1155/2012/206520
Abstract: We present here environmental factors including pH shifts, temperature, and metal ions surrounding Aβ40 monomer to precede the oligomers. We also suggest a new idea to detect Aβ40 oligomers with anti-Aβ40 monoclonal antibody using enzyme-linked immunosorbent assay. This method involves the different sensitivity of the thermal shifts between Aβ40 monomer and the oligomers. The idea is useful for the diagnostics of Alzheimer's disease to detect Aβ40 oligomers in the serum from the patients. 1. Introduction Alzheimer’s disease (AD) is the most common of senile dementia and characterized by memory loss, deterioration of cognitive and behavioral processes and social life, and these symptoms showed no relief through the life. The major pathological hallmark of AD is the accumulated Aβ plaques in the extracellular liquid [1] and neurofibrillary tangles in the intracellular accumulation of hyperphosphorylated and misfolded tau protein [2–4]. Among the brain lesions that are affected in AD and contain the highest number of senile plaques are the amygdala [5] and hippocampus [6]. The amygdala is involved in modulation of behavior, emotion, and memory due to its vast afferent and efferent projections. It has been reported that although lesions of amygdala alone do not appear to impair spatial learning, they potentiate hippocampus lesion-induced disruption of spatial learning [7]. The Aβ plaques are mainly composed of β-structured fibrils made up to β-amyloid protein 40/42 amino acid residues long (Aβ40/42), and they are processed from amyloid precursor protein (APP) in neurons and secreted into the interstitial fluid space (IFS) of the brain in the soluble form [8] and cerebrospinal fluid (CSF) that help to clear Aβ from IFS to the bloodstream [9, 10]. Some of misfolding mechanisms of Aβ to induce aggregation appear in AD brain. Because the aggregated Aβ is observed as extracellular structure, the concentration of Aβ in the ISF [15] and the environmental factors surrounding the protein may affect the process. Detection of the most toxic Aβ species to synapse and neuron [16] present during Aβ aggregation is a critical aspect in AD diagnostics. The molten-globule state of the protein that is a misfolding intermediate, Aβ oligomers before Aβ plaque formation is responsible for neuronal damages [17]. One possible model of direct Aβ cytotoxicity involves the cytopathic effect of amyloid fibrils, which are rich in β-sheets and thereby interact with cell surface receptors and result in aberrant activation of signal transduction pathways. This model in consistent with the
Factors Related to Medication Adherence of Cognitively Impaired Patients in Community Pharmacies  [PDF]
Yoko Nanaumi, Mitsuko Onda, Yusuke Mukai, Rie Tanaka, Kenichi Tubota, Syunya Matoba, Yuka Tanaka, Yukio Arakawa
Pharmacology & Pharmacy (PP) , 2012, DOI: 10.4236/pp.2012.33050
Abstract: Objective: The objective of the study was to identify factors related to donepezil medication adherence (\"adherence\") of cognitively impaired patients in community pharmacies. Methods: One hundred and twenty community pharmacies in 28 regions in Japan were randomly selected. Questionnaires were mailed to these pharmacies. The pharmacists answered based on the medication profiles (\"YAKUREKI\") of the patients given donepezil at their pharmacies. The survey items were \"adherence\", \"who is the key person\" and ‘the key person’s understanding and awareness of donepazil and its symptoms. The χ2 test and decision tree modeling analysis were performed to examine factors affecting adherence. A 5% level of statistical significance was used in the χ2 test. Results: Questionnaires with data on 479 patients were returned. The most common level of adherence was “take as instructed” (81.2%), followed by “forget once or twice a week” (10.2%). The χ2 test revealed that adherence was good if \"key person\" was professional caretaker (P = 0.004). Also, adherence was better if key person understood medication about dosage, P < 0.001; effect, P = 0.002; and general side effects,, P < 0.001. According to decision tree analysis, the key person had the strongest relationship with adherence. Conclusions: It was confirmed that the key person’s understanding of the medication and symptoms of cognitive impairment are related to adherence. In particular, it was suggested that there is a strong relationship between the key person and adherence and that factors related to adherence differ according to who the key person is. It is essential in the treatment of cognitive impairment to accurately identify the \"key person\", in order to provide better pharmaceutical care in community pharmacies.
Factors Related to Medication Adherence of Cognitively Impaired Patients in Community Pharmacies  [cached]
Yoko Nanaumi,Mitsuko Onda,Yusuke Mukai,Rie Tanaka
Pharmacology & Pharmacy (PP) , 2012, DOI: 10.4236/pp.2012.33051
Abstract: Objective: The objective of the study was to identify factors related to donepezil medication adherence ("adherence") of cognitively impaired patients in community pharmacies. Methods: One hundred and twenty community pharmacies in 28 regions in Japan were randomly selected. Questionnaires were mailed to these pharmacies. The pharmacists answered based on the medication profiles ("YAKUREKI") of the patients given donepezil at their pharmacies. The survey items were "adherence", "who is the key person" and ‘the key person’s understanding and awareness of donepazil and its symptoms. The χ2 test and decision tree modeling analysis were performed to examine factors affecting adherence. A 5% level of statistical significance was used in the χ2 test. Results: Questionnaires with data on 479 patients were returned. The most common level of adherence was “take as instructed” (81.2%), followed by “forget once or twice a week” (10.2%). The χ2 test revealed that adherence was good if "key person" was professional caretaker (P = 0.004). Also, adherence was better if key person understood medication about dosage, P < 0.001; effect, P = 0.002; and general side effects,, P < 0.001. According to decision tree analysis, the key person had the strongest relationship with adherence. Conclusions: It was confirmed that the key person’s understanding of the medication and symptoms of cognitive impairment are related to adherence. In particular, it was suggested that there is a strong relationship between the key person and adherence and that factors related to adherence differ according to who the key person is. It is essential in the treatment of cognitive impairment to accurately identify the "key person", in order to provide better pharmaceutical care in community pharmacies.
Behavioral cues to expand a pain model of the cognitively impaired elderly in long-term care
Burfield AH, Wan TTH, Sole ML, Cooper JW
Clinical Interventions in Aging , 2012, DOI: http://dx.doi.org/10.2147/CIA.S29656
Abstract: ehavioral cues to expand a pain model of the cognitively impaired elderly in long-term care Original Research (2911) Total Article Views Authors: Burfield AH, Wan TTH, Sole ML, Cooper JW Published Date July 2012 Volume 2012:7 Pages 207 - 223 DOI: http://dx.doi.org/10.2147/CIA.S29656 Received: 03 January 2012 Accepted: 09 March 2012 Published: 02 July 2012 Allison H Burfield,1 Thomas TH Wan,2 Mary Lou Sole,3 James W Cooper4 1School of Nursing, College of Health and Human Services, University of North Carolina-Charlotte, Charlotte, NC, 2Administration, and Medical Education, Doctoral Program in Public Affairs, College of Health and Public Affairs, 3College of Nursing, University of Central Florida, Orlando, FL, 4College of Pharmacy, University of Georgia, Athens, GA, USA Background: The purpose of this study was to determine the relationship between hypothesized pain behaviors in the elderly and a measurement model of pain derived from the Minimum Data Set-Resident Assessment Instrument (MDS-RAI) 2.0 items. Methods: This work included a longitudinal cohort recruited from Medicare-certified long-term care facilities across the United States. MDS data were collected from 52,996 residents (mean age 83.7 years). Structural equation modeling was used to build a measurement model of pain to test correlations between indicators and the fit of the model by cognitive status. The model evaluates the theoretical constructs of pain to improve how pain is assessed and detected within cognitive levels. Results: Using pain frequency and intensity as the only indicators of pain, the overall prevalence of pain was 31.2%; however, analysis by cognitive status showed that 47.7% of the intact group was in pain, while only 18.2% of the severely, 29.4% of the moderately, and 39.6% of the mildly cognitively impaired groups were experiencing pain. This finding supports previous research indicating that pain is potentially under-reported in severely cognitively impaired elderly nursing home residents. With adjustments to the measurement model, a revised format containing affective, behavioral, and inferred pain indicates a better fit of the data to include these domains, as a more complete measure of the pain construct. Conclusion: Pain has a significant effect on quality of life and long-term health outcomes in nursing home residents. Patients most at risk are those with mild to severe cognitive decline, or those unable to report pain verbally. Nursing homes are under great scrutiny to maintain standards of care and provide uniform high-quality care outcomes. Existing data from federally required resident surveys can serve as a valuable tool to identify indicators of pain and trends in care. Great responsibility lies in ensuring pain is included and monitored as a quality measure in long-term care, especially for residents unable to communicate their pain verbally.
Behavioral cues to expand a pain model of the cognitively impaired elderly in long-term care  [cached]
Burfield AH,Wan TTH,Sole ML,Cooper JW
Clinical Interventions in Aging , 2012,
Abstract: Allison H Burfield,1 Thomas TH Wan,2 Mary Lou Sole,3 James W Cooper41School of Nursing, College of Health and Human Services, University of North Carolina-Charlotte, Charlotte, NC, 2Administration, and Medical Education, Doctoral Program in Public Affairs, College of Health and Public Affairs, 3College of Nursing, University of Central Florida, Orlando, FL, 4College of Pharmacy, University of Georgia, Athens, GA, USABackground: The purpose of this study was to determine the relationship between hypothesized pain behaviors in the elderly and a measurement model of pain derived from the Minimum Data Set-Resident Assessment Instrument (MDS-RAI) 2.0 items.Methods: This work included a longitudinal cohort recruited from Medicare-certified long-term care facilities across the United States. MDS data were collected from 52,996 residents (mean age 83.7 years). Structural equation modeling was used to build a measurement model of pain to test correlations between indicators and the fit of the model by cognitive status. The model evaluates the theoretical constructs of pain to improve how pain is assessed and detected within cognitive levels.Results: Using pain frequency and intensity as the only indicators of pain, the overall prevalence of pain was 31.2%; however, analysis by cognitive status showed that 47.7% of the intact group was in pain, while only 18.2% of the severely, 29.4% of the moderately, and 39.6% of the mildly cognitively impaired groups were experiencing pain. This finding supports previous research indicating that pain is potentially under-reported in severely cognitively impaired elderly nursing home residents. With adjustments to the measurement model, a revised format containing affective, behavioral, and inferred pain indicates a better fit of the data to include these domains, as a more complete measure of the pain construct.Conclusion: Pain has a significant effect on quality of life and long-term health outcomes in nursing home residents. Patients most at risk are those with mild to severe cognitive decline, or those unable to report pain verbally. Nursing homes are under great scrutiny to maintain standards of care and provide uniform high-quality care outcomes. Existing data from federally required resident surveys can serve as a valuable tool to identify indicators of pain and trends in care. Great responsibility lies in ensuring pain is included and monitored as a quality measure in long-term care, especially for residents unable to communicate their pain verbally.Keywords: cognitive impairment, minimum data set, pain behaviors, struc
Absence of amyloid β oligomers at the postsynapse and regulated synaptic Zn2+ in cognitively intact aged individuals with Alzheimer’s disease neuropathology
Nicole L Bjorklund, Lindsay C Reese, V-M. Sadagoparamanujam, Valeria Ghirardi, Randall L Woltjer, Giulio Taglialatela
Molecular Neurodegeneration , 2012, DOI: 10.1186/1750-1326-7-23
Abstract: Here we describe the localization of Aβ oligomers at the postsynapse in hippocampi from AD cases. Notably, however, we also found that while present in soluble fractions, Aβ oligomers are absent from hippocampal postsynapses in NDAN cases. In addition, levels of phosphorylated (active) CREB, a transcription factor important for synaptic plasticity, are normal in NDAN individuals, suggesting that their synapses are functionally intact. Analysis of Zn2+ showed that levels were increased in both soluble fractions and synaptic vesicles in AD hippocampi, paralleled by a decrease of expression of the synaptic vesicle Zn2+ transporter, ZnT3. Conversely, in NDAN individuals, levels of Zn2+ in soluble fractions were significantly lower than in AD, whereas in synaptic vesicles the levels of Zn2+ were similar to AD, but accompanied by preserved expression of the ZnT3.Taken together, these data illustrate that despite substantial AD neuropathology, Aβ oligomers, and increased synaptic vesicle Zn2+, susceptible brain tissue in these aged NDAN individuals features, as compared to symptomatic AD subjects, significantly lower total Zn2+ levels and no association of Aβ oligomers with the postsynapse, which collectively may promote the maintenance of intact cognitive function.
Gerontechnology: Providing a Helping Hand When Caring for Cognitively Impaired Older Adults—Intermediate Results from a Controlled Study on the Satisfaction and Acceptance of Informal Caregivers  [PDF]
Anelia Mitseva,Carrie Beth Peterson,Christina Karamberi,Lamprini Ch. Oikonomou,Athanasios V. Ballis,Charalampos Giannakakos,George E. Dafoulas
Current Gerontology and Geriatrics Research , 2012, DOI: 10.1155/2012/401705
Abstract: The incidence of cognitive impairment in older age is increasing, as is the number of cognitively impaired older adults living in their own homes. Due to lack of social care resources for these adults and their desires to remain in their own homes and live as independently as possible, research shows that the current standard care provisions are inadequate. Promising opportunities exist in using home assistive technology services to foster healthy aging and to realize the unmet needs of these groups of citizens in a user-centered manner. ISISEMD project has designed, implemented, verified, and assessed an assistive technology platform of personalized home care (telecare) for the elderly with cognitive impairments and their caregivers by offering intelligent home support services. Regions from four European countries have carried out long-term pilot-controlled study in real-life conditions. This paper presents the outcomes from intermediate evaluations pertaining to user satisfaction with the system, acceptance of the technology and the services, and quality of life outcomes as a result of utilizing the services. 1. Introduction Dementia is a group of syndromes associated with a loss of memory and other intellectual functions that are serious enough to interfere with daily task performance. There are around 40 types, or causes, of dementia, the most widely known being Alzheimer’s disease. Dementia is commonly associated with aging as the risk for exhibiting symptoms of dementia increases with age, nearly doubling every 5 years after the age of 60. The chances of having dementia over the age of 65 are one in 50 and that increases to one in 5 for those over 80 years and up to 50% in adults over age 85 [1, 2]. Mild cognitive impairment (MCI or CI) is closely related to dementias. Plassman et al. [3] found in their follow-up study that of their participants who had CI and no dementia, nearly 12% advanced to dementia annually. Although MCI is often viewed as a precursor to developing dementia, the relationship is not fully understood. With advancements in medicine, economy, and technology, the human lifespan has increased significantly over the last decades; additionally, dementia rates have increased [4] and this poses questions about the quality of extended years of life. In the context of ISISEMD project, we use quality of life (QOL) to mean “the individual’s perception and evaluation of the impact that the disease and its consequences have produced in their lives” [5]. As there is no cure for dementia and current treatments serve only to reduce the
Mechanism of Prion Propagation: Amyloid Growth Occurs by Monomer Addition  [PDF]
Sean R. Collins,Adam Douglass,Ronald D. Vale,Jonathan S. Weissman
PLOS Biology , 2012, DOI: 10.1371/journal.pbio.0020321
Abstract: Abundant nonfibrillar oligomeric intermediates are a common feature of amyloid formation, and these oligomers, rather than the final fibers, have been suggested to be the toxic species in some amyloid diseases. Whether such oligomers are critical intermediates for fiber assembly or form in an alternate, potentially separable pathway, however, remains unclear. Here we study the polymerization of the amyloidogenic yeast prion protein Sup35. Rapid polymerization occurs in the absence of observable intermediates, and both targeted kinetic and direct single-molecule fluorescence measurements indicate that fibers grow by monomer addition. A three-step model (nucleation, monomer addition, and fiber fragmentation) accurately accounts for the distinctive kinetic features of amyloid formation, including weak concentration dependence, acceleration by agitation, and sigmoidal shape of the polymerization time course. Thus, amyloid growth can occur by monomer addition in a reaction distinct from and competitive with formation of potentially toxic oligomeric intermediates.
Mechanism of Prion Propagation: Amyloid Growth Occurs by Monomer Addition  [PDF]
Sean R Collins,Adam Douglass,Ronald D Vale,Jonathan S Weissman
PLOS Biology , 2004, DOI: 10.1371/journal.pbio.0020321
Abstract: Abundant nonfibrillar oligomeric intermediates are a common feature of amyloid formation, and these oligomers, rather than the final fibers, have been suggested to be the toxic species in some amyloid diseases. Whether such oligomers are critical intermediates for fiber assembly or form in an alternate, potentially separable pathway, however, remains unclear. Here we study the polymerization of the amyloidogenic yeast prion protein Sup35. Rapid polymerization occurs in the absence of observable intermediates, and both targeted kinetic and direct single-molecule fluorescence measurements indicate that fibers grow by monomer addition. A three-step model (nucleation, monomer addition, and fiber fragmentation) accurately accounts for the distinctive kinetic features of amyloid formation, including weak concentration dependence, acceleration by agitation, and sigmoidal shape of the polymerization time course. Thus, amyloid growth can occur by monomer addition in a reaction distinct from and competitive with formation of potentially toxic oligomeric intermediates.
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